# Disparities in the diagnosis and management of exocrine pancreatic insufficiency in resectable vs metastatic pancreatic cancer

## TL;DR

This study finds that exocrine pancreatic insufficiency is common in pancreatic cancer patients but often underdiagnosed and undertreated, especially in those with metastatic disease.

## Contribution

The study reveals disparities in EPI diagnosis and treatment between resectable and metastatic pancreatic cancer patients in a U.S. real-world setting.

## Key findings

- EPI symptoms occurred in 58% of metastatic and 68% of surgical patients, but fecal elastase testing was rarely performed.
- PERT was underdosed in most patients, with only 33–44% reporting symptom resolution before the intervention.
- A quality improvement initiative significantly improved PERT dosing and led to 74.1% of patients achieving complete symptom resolution.

## Abstract

Exocrine pancreatic insufficiency (EPI), a common complication of pancreatic cancer (PC), reduces quality of life and may shorten survival. While pancreatic enzyme replacement therapy (PERT) improves symptoms and outcomes, real-world patterns of EPI workup and PERT use across PC subtypes remain poorly described in the United States.

We retrospectively analyzed 250 patients with resectable or metastatic PC from a single institution’s prospectively maintained registry (2013–2018), collecting data on clinical characteristics, EPI symptoms, fecal elastase testing, and PERT prescriptions. In addition to the retrospective analysis, a quality improvement intervention for EPI management was implemented (1/2021–1/2023), and outcomes were analyzed.

Among 250 patients, 97 underwent surgery for resectable disease and 153 received non-surgical management for metastatic PC. Exocrine pancreatic insufficiency symptoms occurred in 58% of metastatic and 68% of surgical patients. Fecal elastase testing was rarely performed (2% vs 9%, respectively). Pancreatic enzyme replacement therapy was prescribed to 46.5% of metastatic and 84% of surgical patients, but average doses were suboptimal (18 500 vs 20 000 USP units per meal; recommended: ≥40 000). Among those on PERT, symptom resolution was reported in 33% of metastatic and 44% of surgical patients. Contrasting with results from the retrospective analysis, the quality improvement intervention led to 90% of 41 participants being prescribed PERT at an average dose of 44 700 USP units per meal. Treated patients (74.1%) experienced complete resolution of EPI symptoms.

Despite prevalent EPI symptoms in PC patients, fecal elastase testing was infrequently utilized, and PERT was often underdosed. Educational initiatives are needed to improve guideline adherence and optimize outcomes.